The management of shotgun wounds

Peripheral Arterial Injuries with Gunshot Wounds: Surgical Treatments and Results

Between 1975 and 1985, 102 consecutive patients with 106 peripheral vascu lar injuries caused by gunshot blasts were treated in the authors' clinic. The average age was 25.6 ± 11.4 (mean ± SD). The average time between arterial injury and arrival to the hospital was 13.2 ± 4.8 hours. Sixty-six (62.3%) arte rial injuries were found in lower extremities and the most commonly injured artery was the superficial femoral artery. Thirty-six (35.3%) patients had com bined arterial and venous trauma. All patients with vascular involvement had some signs and symptoms of vascular trauma. Preoperative angiography was required in 23 cases and demonstrated arterial injury; 98 patients underwent surgical intervention. Resection of the injured arterial segment and end-to-end anastomosis were done in 44 patients. Resection of the arterial segment followed by interposition of autogenous vein graft was done in 34 patients. One case underwent nonbiologic graft (Dacron) replacement (in the left subclavicular ar tery). Primary lateral suture was placed in 6 cases, and ligation was made in 9. In cases associated with venous injury, 22 vascular venous repairs and 14 liga tions were done. Eighty-one (79.4%) patients retained a functional limb. Two cases underwent primary amputation, and 9 cases underwent secondary ampu tation. Six patients died; the causes of morbidity were usually related to associ ated injuries. Four patients refused the surgical approach.

Bedside open abdominal surgery. Utility and wound management

Abdominal pathology in the critically ill or injured patient frequently leads to the use of open abdominal techniques or the actual performance of abdominal surgery in the ICU. All individuals responsible for the care of patients in the ICU should be familiar with the concepts and techniques of open abdomen wound management. ICU bedside abdominal surgery may be indicated if the patient is too unstable for transport to the operating room and the surgeon believes a limited procedure, such as a decompression of IAH, will be life-saving. Smaller procedures are also feasible, such as intra-abdominal packing changes for which the operating room is unnecessary. Development of a successful Surgery Outside the Operating Room program depends on mature cooperation between the surgeons and other professional ICU staff. Logistic details of such a program should be discussed and a scheduling protocol should be prepared before an emergent need for bedside surgery.

Management and outcome of abdominal shotgun wounds. Trauma score and the role of exploratory laparotomy

OBJECTIVE

The management and outcome of 138 abdominal shotgun wounds were examined over a 5-year period.

SUMMARY BACKGROUND DATA

It has been proposed that exploratory laparotomy may be unnecessary and even overused in a subset of patients with abdominal shotgun wounds.

METHODS

Data on shotgun wound patients from October 1987 through March 1992 from a statewide trauma registry were examined. Patients with abdominal shotgun wounds were identified and compared with patients with nonabdominal shotgun wounds.

RESULTS

Of 516 shotgun wound patients, 138 (26.7%) had abdominal wounds and 88 (63.8%) had exploratory laparotomies. Abdominal shotgun wounds resulted in significantly longer number of intensive care unit days (4.3 vs. 2.5, p < 0.05), a greater number of blood units transfused (7.8 vs. 2.4, p < 0.05), and a higher mortality (15.9% vs. 4.8%, p < 0.05) when compared with nonabdominal shotgun wounds. When stratified for trauma score, the mortality for abdominal shotgun wounds always was significantly greater than for nonabdominal shotgun wounds. All abdominal shotgun wound patients with trauma scores less than ten died. The negative laparotomy rate for abdominal shotgun wound patients with normal trauma scores was 9.4%. No patient with a negative laparotomy died.

CONCLUSION

Abdominal shotgun wounds are a particularly lethal subset of shotgun wounds. Although some abdominal shotgun wound patients can be managed without laparotomy, the morbidity and mortality for these injuries are substantial, even in patients with normal trauma score. Clinical judgment is an excellent predictor of the need for laparotomy.

War injuries to the bone and joint system: reconstructive surgery

Reconstructive bone and joint surgery in war is discussed. Bone and joint injuries account for over 70% of all injuries, 30% including a fracture. They pose a serious medical, surgical, and public health problem. The methods described aim to restore full function to the injured extremity. War injuries incorporate severe circulatory disorders and severe soft tissue and bacterial contamination. The war surgeon is faced with defectively healed or unhealed fractures, bone and tissue defects, joint injuries, traumatic amputations, large joint contractures, and infections. Clinically, external fixators, the Ilizarov method, antibiotic prophylaxis, and a new antiseptic agent have proved highly beneficial.

Extraanatomic bypass for peripheral arterial injuries

Over an 8-year period, extraanatomic bypass grafting was performed for peripheral arterial injuries or infections in 12 patients. The indications for use of the technique were as follows: (1) extensive loss of soft tissue over arterial injury or avulsion; (2) wound infection with rupture of a previous arterial repair; or (3) combined infections in soft tissue and the underlying artery due to illicit drug injection. The technique involved excision of the injured or infected artery beyond the margins of the debrided wound and insertion of an autogenous saphenous vein as an extraanatomic bypass graft in a medial or lateral position around the wound. Shotgun wounds were the mechanism of injury in six patients, whereas an extensive injury or infection in the brachial artery was present in eight patients. Successful wound coverage or closure was accomplished and distal arterial flow preserved in 11 patients, 5 of whom had residual neuromuscular or bony defects related to the magnitude of the original injury.

Management of civilian gunshot wounds in a Nigerian general hospital

In a 3-year period (1981-1984), 52 male patients aged 10-60 years were treated for fresh gunshot wounds. The injuries varied from minor soft tissue injuries to major organ and tissue damage, and were all sustained by low-velocity missiles. Six of the patients (11.5%) died of their injuries or complications while 46 (88.46%) survived and were discharged after 1-15 weeks (a mean hospital time of 3 weeks). Some of the patients were treated before referral and for some there was a delay of more than 48 h before definitive specialist treatment. Mortality was related to the severity of wounding and the delay before treatment.

Selective management of gunshot wounds to the neck. Report of a series and review of the literature

Thirty-two patients with gunshot wounds to the neck, 13 with multiple pellet injuries and 19 with single missile injuries, were managed selectively. Although 3 of the 32 patients died in the hospital, no death was attributable to the neck injury. This experience and a review of the literature support the concept of selective management of penetrating neck injuries with intervention based on specific indications.